Breaking Bad

All that you never wanted to know about Anterior Cruciate Ligament (ACL) Reconstruction Surgery

As some of you know, I recently suffered from a ligament injury. This blog post is meant to give some background and update on the injury to the people who know me, and to serve as an informational resource to others who might be going through a similar issue.

Short story:

1998. Boy meets girl, girl meets boy. Boy professes his love to the girl. Girl accepts. Fast forward 15 years. Boy & Girl – now happily married (and to each other!) – go to Switzerland to celebrate the special anniversary. Boy decides to ski in Zermatt, has two bad falls, and damages ligaments in his knee. They complete their trip, come back to India, and the boy then goes through knee surgery. He is now recovering quite well and has started walking. Running, and more importantly, riding his bullet motorcycle are still 6 months away. Much to the delight of one of his friends, who is happily thumping along on the cycle for the interim period.

The Long Version:

I will skip the boy meets girl part – that’s better narrated in-person. :)

Let me start from the fall at the ski resort. This happened in Zermatt – an absolutely gorgeous, car-free town in Switzerland. Zermatt’s ski resort is quite famous – it has Europe’s largest summer ski runs and is one of the most preferred places for professional skiers to practice during the summer & fall months.

(2nd Sep 2013. In Zermatt. Matterhorn in the background. One day before the fall)

Anyway, as I started skiing, fell once, and most likely partially tore one of the side ligaments of my knee (the MCL). I realized after the fall that I needed to pack & go back. I also noted that the only way to go back was to ski all the way down the slope. I started doing that, and as I was navigating a turn, felt a searing pain in the MCL due to which I couldn’t balance myself, and went into a completely uncontrolled fall. Pretty bad one. Once I had stopped tumbling, I found myself howling away in pain on the ski slope. After a few minutes, a nice person stopped by, and we communicated in broken English

Me: “Help. Knee. Pain. No Ski”

“Bring doctor – here?”

“No, no doctor. I go back. To Hotel”

“Ok. I go down, tell office. Ok?”

“Yes, danke. Danke so much!”

15 agonizing minutes later my savior came on a ski mobile. The first question he asked was “Do you have a credit card?” I’ve never been happier with my Capital One card.

(In cable car, on the way back from the ski slope. Notice the bump on the left side of the knee)

About an hour later, I was back at the hotel, narrating the incident to Neha & discussing next steps.  We went to the amazingly nice local doctor, who confirmed that I didn’t have a fracture but most likely had damaged one or more of my ligaments.  I was told to “pay the PRICE and do no HARM”:

PRICE = Protect, Rest, Ice, Compression, Elevation

No HARM = No Heat, Alcohol, Running, Massage

Interesting outcome of this – the doctor told me to take some injection to prevent DVT (blood clots) on the flight back. And since we were going to do a bit of traveling for the next few days, he taught me how to apply the injection myself. We took turns, just for the fun of it – I did it once and Neha did it the second time. That was a new experience that I wasn’t expecting to come out of the Swiss trip!

Anyway, 4 days and 7000 miles later, we were back in Delhi/Gurgaon, where an MRI confirmed that I had

(a)    a partial (grade 2) tear of the MCL,

(b)   a full (grade 3) tear of the ACL

By this time, I had learnt that:

·         Knee ligaments prevent the knee from unnatural movement, such as excessive sideway movement, twisting movement, etc. There are four such ligaments in each knee

·         If there is a large degree of unnatural movement with significant amount of force, the ligaments get damaged or torn

·         ACL injuries are fairly common while playing football (both kinds), basketball, and skiing

Here’s a short (about 5 min) but very informative video on the ligaments, their purpose, what happens when you tear the ACL, and an overview of the surgery

(Note that the surgery example given here uses a graft from the hamstring. The one that I got done used a different graft – more later)

A partial tear gets fixed by itself (as long as you protect it). A full tear can’t be fixed and you have two broad options:

a.       Live with a torn ACL: Usually recommended for the elderly or those who don't live very active lives. The risk is that your knee will keep hurting and can give way with even a minor misstep

b.      Get surgery done to reconstruct the ACL: Recommended for most people less than 60/70 years of age. The surgeon will remove the torn ACL and insert a “substitute” ACL. The substitute could be “harvested” from:

a.       Part of your own hamstring

b.      Part of your own Patellar Tendon (the ligament that joins the knee cap to the shin bone)

c.       From a cadaver

There’s much discussion about which kind of ACL reconstruction to go for. Here’s what I have learnt (note that I am by no means a professional – you need to talk to your doctor if you are evaluating this decision):

1.       Cadaver harvesting is less painful. But chances of complications are more, since there’s a foreign body being inserted into your knee. Also, the ACL might give way after a few years and might need replacement again

2.       The differences between hamstring vs. PT harvesting are minor. If your surgeon is more comfortable with one vs. the other, then go with whatever he/she wants to do. PT harvesting does leave a bad-ass scar (4-5 inches), so if you care a lot about that, you can go with the hamstring option

Here’s a great resource with more information: http://orthoinfo.aaos.org/topic.cfm?topic=a00297

My surgeon wanted to evaluate the condition of the knee during surgery and make the decision then between Hamstring vs. Patellar Tendor. I was cool with it. He ultimately went with PT.

Surgery.

I was brought into my room at about 8am. Preparations started in full swing. A battery of tests was done. I was given a good shave of the leg. A big fat arrow was made on my left leg using a marker pen (to remind people which leg to operate upon). I was asked to change into this pink attire:

(Don't mess with me, even if I am wearing pink!)

I was wheeled away from the room around noon, from where I was taken to the pre-surgery prep room. That’s where two questions were asked at least 15 times at different stages:

“Which leg is it”

“When did you last eat or drink something”

I am glad that the folks at Medanta don’t leave any room for error here.

I was then administered regional (spinal) anesthesia. The thing is injected into the spine – it hurt more than a regular syringe, but less than how much I thought it would – what with the needle going into a bone etc. Within 5 minutes, my lower half of the body was completely numb. The surgeon joked that even if I wanted to run away from the surgery, I could no longer do it, given that my brain couldn't control my legs.

I was then taken into the OT, where the operation lasted for about 45 minutes (or so I’m told). The surgery is done using arthroscopy (fancy word for camera-assisted). Here’s a fascinating video of the entire procedure (This is not the video of my surgery, but the operation is identical to mine. Note: Graphic Advisory):

("Glorified Carpenters" at work - in words of my surgeon)

I could hear the drills, the hammer, feel being pushed & pulled, but magically (&thankfully) didn’t feel any pain at all. I wanted to see the operation, but they had put curtains to prevent me from doing it. My surgeon had promised me that he'd give me a DVD of the operation (which I now have!).

The down side of the operation was that half-way into the procedure I started feeling queasy, dizzy, and threw up. This happened multiple times in the post-operative area and later in my room as well. I was told that my body reacted strongly to the anesthesia, and this does happen to a few people.

Post-surgery

Quick notes post surgery:

·         The attendant (Rhea) during my stay in the hospital was awesome. Neha was extremely uncomfortable in leaving me alone, given that I was puking my way to glory. The attendant tried to convince her that she was there at the press of a button, but Neha requested her to stay by me the entire night. And she did! The entire night, she sat inside the room by the entrance, doing her paperwork in the light coming from the bathroom. Once I started feeling better, I told her that she could go back to her attendant station, but she said that she had promised Neha she’d be there by me, and so she wasn’t leaving. I was just bowled over by this dedication. Thanks sister Rhea – I will never forget this!

·         There was pain and discomfort the first night, and I didn’t get much sleep

·         Was discharged from the hospital the next day. The incisions in my knee had been stapled (21 staples in all!!) and the leg was wrapped up tightly in crepe bandage. Finally, a dial-a-loc brace was fitted, that prevented any knee bending. I was allowed to walk using a walker

(Another use for Milton's stapler!)

Note: This pic was taken 2 weeks after surgery, hence the absence of swelling

·         The crepe bandage felt too tight. Apparently the doctor had told my wife (when I was puking away) that when I come back to my senses, I will start complaining about how tight the bandage was, and that is to be expected. That’s exactly what I felt. It all started to feel better after 3 days

·         Pain subsided significantly after the 3^rd night, just as the surgeon had predicted

·         I couldn’t lift my leg at all for the first 4-5 days. Getting in and out of bed was difficult – someone had to lift the leg for me

·         Key thing during the first few days is to make sure you don’t keep anything (pillow etc) under the knee. Your knee should be perfectly straight. And keep doing the few exercises they tell you to do – especially the one in which you need to tighten your thigh muscles. You can’t do enough of those

·         Garbage bags come in very handy to water-proof the leg as you are taking a shower

·         I had a lot of swelling in my ankle. A lot - it felt like the foot would burst! Apparently its normal. Keeping the leg horizontal helps. Keeping it above the level of the heart helps even more

·         If you feel uncomfortable with the brace and can’t sleep, don’t worry. You’ll get used to it very quickly. The brace is extremely important while you are sleeping – it makes sure you don’t do anything stupid in sleep. Don’t remove it unless your doctor allows you to

·         Having to sleep in one position the entire night was a bummer. I kept getting up a few times every night

·         I started a little bit of work (from home) day 2 post surgery. But couldn’t accomplish much in days 2-5, partly due to the uneasiness & pain, and partly due to headaches that I was getting which were the after effects of the anesthesia. Starting day 5, I resumed work (still from home) with about 80% efficiency. I plan to start going to the office now (2 weeks from surgery), given that I can now bend my knee

Current condition:

I’ve completed 2 weeks post surgery (and 4 weeks post incident). I got the staples removed yesterday and am now allowed to walk using a stick.

(On way to getting the staples removed and knee lock relaxed. Can you feel the excitement?)

I can (and need to) bend my knee as well. Currently I can manage about 45 degrees, but will most likely be able to go to 60 degrees in a few days. 90 degrees will come in a week or so (all of this per my fabulous surgeon Dr. Vivek Dahiya of Medanta, who’s been spot-on with his predictions so far). The walking stick / crutch will go away week 6 post surgery. Driving can start week 8. Running is 6 months post surgery. Intense sports (soccer, skiing, etc) can resume 12 months post surgery. The speed and amount of recovery depends upon how well do I stick to the physiotherapy regime. It might also depend on how much fun I have with all the attention I am getting these days – here are a few examples:

(Foot painting in action. You can still see the arrow mark that was painted pre-surgery)

(I am now a work of art - Guess this whole surgery thing ain't that bad)

So that’s it folks. Thanks to the awesome staff at Medanta. Thanks to everyone for their wishes. And big thanks to Neha for being the most patient wife ever!

Cheers!